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Medicine From The Trenches

In the twenty years that I have practised medicine/surgery, nothing like this COVID-19 disease epidemic has been my experience. I was practising in Washington, DC during the attack on the Pentagon on September 11, 2001; a time when I thought nothing could be worse. Well, this viral pandemic is worse because many people only listen to what that WANT to hear rather than what the NEED to hear. I see the worst examples of noncompliance in those who had little trust for science and medicine in the first place.

Having performed bariatric surgery on a population of people who have dire mental health and physical needs, I see many of the same behaviours in people who are not adapting to this 2020 pandemic. I see hoarding behaviour; a sign of anxiety. I see anger; a sign of depression and I see fear; understandable because this is a new situation for all of us in this country. Most frightening for me is seeing large non-compliance in simple matters that will affect how this virus can spread.

Some of my undergraduate students boasted that they are strong and healthy thus they don’t have to worry about COVID-19. Some of my neighbours had a birthday party with 20 guests using the rationale that they couldn’t bear to disappoint their son or daughter. Some have blatantly questioned that this pandemic is even “real” because the news media always tries to frighten “good” people. For me as a practising physician who cares for the health of a community, the non-compliant people are frightening.

I developed some automatic self behaviours long ago such as removing my shoes when I enter my house; washing my hands often (I am a surgeon); not touching my face without washing my hands and cleaning my house from top to bottom weekly. My sweetheart calls me a “neatnik” because I constantly remove clutter both in my offices and on my computer. These are habits ingrained since childhood but I add to them with keeping a bottle of hand sanitizer next to my front door and keeping a table on my porch for packages that are cleaned before they come into my house.

Along with my neat and clean environment, I add making sure that I exercise a minimum of 30 minutes per day (I usually run 90 minutes at 3AM daily); eating well-balanced meals (easier now that restaurants are not open) and getting a solid amount of rest/sleep (harder because I am working longer hours). I practise mindfulness when I feel stressed though long ago I learned that regular aerobic exercise removed much of the stress from my life. I practise yoga and calming in a minimum of two sessions daily.

I have learned to relish my reading time more and more but miss attending plays and productions. I miss the NHL and NBA along with rooting for my university basketball team. A quick listen to news reports brought a sense of grief that while I hear birds singing, there is no baseball. I have replaced my love of watching sports by watching cooking shows where I learn new combinations of spices and foods. I have picked up a couple of novels to read and enjoy because I have completed my journal reading more efficiently these days.

Finally, this virus gave me a chance to examine every automatic gesture and movement when I am in a patient’s room. I am constantly vigilant about maintaining a social distance for the safety of my patient. When I am in contact with a patient, I make sure that I am wearing safety devices because we don’t know who is positive or who is negative for this very contagious SARS-CoV-2 virus. We use universal respiratory precautions for all patients for the safety of every healthcare worker. I remind my colleagues to go home, interact with their families and to be safe. This is our new normal for the months to come but still, there is joy in practising medicine and serving others in this time of increasing danger.

Here we are at the beginning of a pandemic with a new virus here in the United States. I returned from a much-needed vacation in the southern California desert where I took the opportunity to re-educate myself (a surgeon) on dealing with a new respiratory virus that now appears more contagious than the influenza virus; a threat but not the end of the world as we know it. Back at home, my institution of higher learning let me know that we would be going to remote learning for most of our students.

For me, here’s a real-time lesson in first, why I took the Hippocratic Oath to first do no harm. I had been telling my students for months, to exercise good and proper handwashing and to stop touching their faces. I had emphasized the need to get and stay in the good physical condition and I had emphasized regular vigorous exercise to reduce stress along with a diet that is lower in alcohol, junk food and high-fat foods. There is nothing new about doing these things to keep healthy. First, do no harm to oneself.

Along with taking care of yourself, you have to take “care” of others. This means being calm, well-informed and kind to others. This means moving your focus away from yourself and outward to your patients and relatives who might be frightened and very misinformed. As I watched people hoarding food and household items, I emphasized to all around me, to be calm and not to panic. Staying safe now means staying relaxed and as stress-free as possible.

Look at the bright sunshine and blue sky. Take a few breaths to relax. In the coming weeks, you will be closer to those that you love and care about. Hold them close and hold yourself closer with kindness and understanding. After that, change what you are used to doing for relaxation replacing with reading something that isn’t medical, catching up on Netflix and keeping grateful for simply having a roof over your head. These are simple things. Take this opportunity to work on setting your study habits at home rather than in a classroom.

Next, if you are in your clinical years, practice excellent use of personal protective devices but don’t panic. Show your patients that you are healthy, calm and ready to care for them. Show your less-educated allied health workers that they don’t need to panic but to be professional and caring. As I walked into my hospital this morning, I greeted everyone with my usual smile and upbeat manner to emphasize that it was good to see most of them. I simply will not tolerate panic and over-bearing stress.

My students need not worry that they can’t complete their education. As an educator and a teaching physician, I will make sure that you have the best opportunity to grown and learn with this new opportunity to study and learn on a daily basis. I will continue to give the best information. I will continue to remind you that you can make the best use of your electronic tools and I will continue to remind you to listen to people who have studied and weathered these “pandemics” with organisms that were far deadlier than this virus.

Now, it isn’t about you but it’s about all of us as a society. This virus has emerged and given us an opportunity to reboot and renew ourselves as we care for others especially the most vulnerable. As I watch people stuffing shopping carts and in some cases, attempting to hoard things, I remember that we all have enough and will have enough of everything except kindness and caring. Relax, care for yourself and continue to care for others with safety and kindess.

16 March, 2020

Posted by drnjbmd |
medical school, medicine |
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The new proposed changes in USMLE Step I take this test from a numerical score to Pass/Fail. Make no mistake, this exam will continue to be high stakes especially if one fails this exam. By making this exam Pass/Fail, it becomes a baseline standard for assessment of whether or not one has the basis for clinical work in medicine.

While I am happy to see that the USMLE Step I becomes more of a minimal standard that one should be able to meet, I do want to emphasize that failing this exam become more of a liability for medical students. It is my hope that one will plunge into their pre-clinical coursework with vigor for gaining a knowledge base to build upon clinically. I would also hope that this change will allow students to stop using a single score on a single exam as a means of comparing themselves to others.

It has been my experience that exam scores may assess critical thinking skills and knowledge base but no exam can assess grit, determination, and resilience which are as important in medical practice and training as knowing the right answers. This is where I hope the changes will most affect students. I hope that they will pursue their studies with grit, determination, and resilience so that they will gain a knowledge base that will move them forward.

Medical students in this country already know how to learn and achieve. They would not have gained admission into medical school with learning and achievement in their pre-medical science and undergraduate studies. Medical school admissions have tested their resolve to learn and demonstrate that they have a broad range of talents that will get them through their medical school classes. What is very difficult to assess but may be learned in how to become a physician who can utilize their medical science knowledge in the treatment of patients. In short, one has to learn to become a physician and will constantly learn for the rest of one’s life.

For me, the transformation of becoming a physician is never over. I am constantly observing humanity, connecting with humanity, and challenging myself to do better with each patient encounter. Being able to treat my fellow humans is never routine or boring and as such, never something that I can ever “take for granted”. I have to give everything that I can give to each patient sometimes under duress and less than ideal circumstances. In short, medicine and its practice for me is never perfect or routine but always a wonder and a joy.

My patients don’t care if I am on my 40th hour or on my first hour because when they encounter me, it’s never by choice. I chose the demands of this profession but they don’t choose to be sick. I always have that thought in my brain as I enter each room. While the new changes in USMLE Step I may lessen competition and perhaps, take some money out of the coffers of USMLE prep companies, the changes do not change the ultimate goal and that is to become the best physician that one can become. To practice medicine is to keep practicing until one gets it as right as possible.

I can recommend regular movement more than now in our lives as humans. Humans were simply made to walk upright and move from place to place. Even our eyes are placed in our heads so that we can see where we are going, with a head turn, where we were. Our regular movement need not be more than 30 minutes of walking, or doing anything briskly enough, to get one’s heart rate high enough; perhaps break a sweat if we are fortunate.

I spent four years in medical school, the first two years studying and not moving. It was easy to go from being a very active graduate student/professor to sitting and studying large amounts of information for demanding coursework. The most active I became during those two years, was to move around a cadaver tank during dissection. My inactivity was a mistake.

My inactivity allowed me to begin…

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20 January, 2020

Posted by drnjbmd |
medical school |
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From time to time, many of my undergraduate students have asked questions about the Medical College Admissions Test (MCAT). Since 2016, the test changed but it isn’t more difficult just different. Some of those differences are designed for students who have interests in more than straight physical science. The new test has four sections instead of three (the one I took years ago).

The MCAT still asks students to demonstrate knowledge and application of knowledge of pre-medical coursework. The test is not the regurgitation of pre-medical coursework concepts but the application of those concepts to problems on the test. Many of these problems are similar to problems encountered in research and scientific study. In this way, the new edition of the MCAT is still close to the old version.

If you took the old MCAT and are applying to medical school in the near future, your schools may want you to re-take the new MCAT. While this is an expense, it is necessary for you if required by the schools that you anticipate applying to. Check with your potential schools for guidance in this matter.

The preparation for the MCAT hasn’t changed in my opinion. One still needs to be a good critical reader and a thoughtful student. One has to not only learn concepts but be ready to apply those concepts as needed. One needs a thorough grounding in scholarly inquiry and sound study skill in all coursework. One need not major in science if science is not particularly appealing but take the pre-med coursework in addition to courses in one’s subject major.

Thoughtful and critical reading/study are skills that can be mastered from the first day of college work. These skills may be honed in primary and secondary school but put in action as you begin university. If you feel that you lack these skills, take advantage of every free study skills course offered at your university. Allow your faculty adviser to point you to courses such as critical reasoning that will further elevate your skills.

I am an advocate for students taking some manner of creative or performance course in addition to coursework in their major subject. Courses such as public speaking, acting and music/dance can allow you to be aware of how you communicate with your physical instrument (mind, voice and body). This past summer, I took an Acting 1 class with freshman undergraduate students where I learned more from my fellow classmates than I learned from the professor. Working with a group on various scenes and projects was enlightening for me as a professor in that I had picked up some “bad” habits over the years of being a surgeon/professor. I strive to change those habits.

Don’t forget to go to the MCAT site as soon at you decide that medicine is your quest so that you may download the subject content of that test. You must make sure that you have learned the concepts tested on each of the four sections of the MCAT. You might use the subject content to make a checkoff list to ensure that your preparation will be on track for this important standardized exam.

Finally, please don’t approach the MCAT with the idea that you will take this exam more than once. While we may not get all of the scores, we do get notification of attempts. A “red flag” goes up with an application that contains many attempts on the test whether or not scores are present. This is not a “do-over” kind of exam under the best of circumstances. Plan on taking the exam once (when you are thoroughly prepared) and scoring your best. Don’t fear this test but treat it as one more step closer to your goal of being a physician. Take each step as it comes and prepare for each step.

The time has come for senior medical students in the United States to enter the Match where they will seek post-graduate residency training. This residency training is key to medical practice in that board certification, the standard of medical practice requires residency in addition to licensure for practice in the United States. All clinical medical jobs in the US require licensure and the vast majority will require speciality board certification which requires residency.

With that being said, there are more senior medical students graduating and competing for available PGY-1 positions whose numbers have remained static in the face of an increasing number of graduates. Adding to the number of competitors are graduates of foreign medical schools who want to train in the United States. With increasing competition for available slots, some graduates (both foreign and domestic) will remain unmatched.

The vast majority of unmatched graduates will re-enter the match but that means finding something to do for a year. Unfortunately, the Match only happens once per year which makes finding oneself unmatched devastating and a heavy blow after four years of diligent study and hard work. Make no mistake, if one intends to practice medicine in the United States today, one has to come to terms with the Match.

I will be the first to say that I hate this system as it exists today. With the need for good physicians dire in the United States, I want everyone who wishes to have good training for practice to find a good training program without question. I also hate that the selection process is very subjective which can favor people who have personal connections to programs. In my opinion, there has to be a better way of getting people into programs so that they may be trained to practice because we need them.

Most residency programs will look at medical school performance and performance on licensure exams as their main criteria for inviting applicants for interview. Those who have high grades and high scores on licensure exams will be at an advantage especially for programs in competitive specialities. Other things that can push an applicant forward especially during interviews would be physical attractiveness and an engaging personality which again are subjective but let’s look at those folks who may struggle to find a position.

Things that may cause struggle in the Match would be the failure of any class, rotation or licensure exam. Hundreds of applicants may have one of these items on their application which may be problematic for them. If this turns out to be the case going into the Match, I would strongly advise that the applicant make sure that the reasons for failure/less than strong performance are addressed and thoroughly explained.

If one has endured four years of medical school with some bumps or failures in the road, they must spend some time with their Deans and professors to make sure that they post the strongest application possible. Any failure and these are not personal failures because the entire medical school process has more than tested these individuals are things that have to be transparent. I cannot emphasize more that if there are major problems, don’t sit out the Match but address the problems and enter having received crucial advice and critique from the Deans and professors at your medical school.

Perhaps one might not be a star, few stars exist, but having a licensure board failure, course failure or rotation failure does not define work ethic, ability to practice medicine or ability to thrive in a post-graduate training program. Every human being will have trials but it’s been my experience in medicine/surgery that those who have been tried and succeed, are the people I want in medical practice.

As thousands of fourth-year medical students head out on those interviews, don’t apologize for not being perfect but find a way to allow those interviews to see your passion for medical practice. Make sure that you find out as much as possible, about the programs that invite you for an interview and use the day to show your magic. If you have made it through four years of medical school, you have the magic thus, let it shine.

For those who have been accepted and starting medical school, congratulations. It’s affirming to start a new journey especially one that is long-term and a step towards a goal. I certainly remember the days of sitting in orientation for my medical school with questions, anticipation, and hope. I remember the wonder of all that I would undertake in the upcoming months.

I participated in our school’s White Coat Ceremony which is always an affirming experience. I remind myself of the privilege of treating patients and the absolute magic of making a difference in the life of my fellow humans. I remind myself that every human being is in the image of our creator with feelings and hopes of getting back to good health. I remind myself that my experience and training have to continue with every patient encounter. This is never a job for me but a calling that brings joy and stress sometimes but is a gift.

My late Pop was a physician who always encouraged me to remember that I have to give my best when I am tired, frustrated, and busy. I remember the words of my professors, my teachers, and those who take the time to help me give my best for my patients. I remember that my patients do not come to my care by choice but by need. While I chose this profession, my patients do not choose to be ill.

I remember every long day of rushing around for class and studying late into the evening. I remember the magic of understanding and finding structure in my Gross Anatomy dissections. I remember the joy of every slide examined in my Pathology class and I remember final mastery of the skills for a sound physical exam in my Physical Diagnosis class.

I didn’t become a higher life form by acceptance into medical school or the study of medicine. I became a person of service to my fellow human beings. Even today, I work to be a keeper of their trust and a better servant to those who come into my care. Even today, I read journals, study consistently in order to be the best professor that I can be.

I learn from my students and I teach my students as best I can. The best of what keeps me going after many years of practice is that I surround myself with those who see the wonder of all humans, who love what they do, and who continue to hone the skills that make them good educators.

If you are starting this journey of medical school, remember that this education is going to open the door to a lifetime of service to others. Remember that you have to give everything even when you believe you can’t give any more. Remember that your fellow classmates are going to be people you will refer and consult for your future patients; be cooperative and not competitive as you won’t practice alone; appreciate and nurture those who study with you. Always have to courage to ask for help early and often but enjoy this new journey.

17 August, 2019

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medical school |
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You have studied diligently and completed/are completing your coursework as best you can. Now, is the time to get all of your information and materials organized and keep them organized. Things to do right now:

Make a complete list of all of your Letter of Recommendation writers that includes the date the letter was requested, the full contact information for your letter writer- you need this for completing thank-you’s for them doing this.

Make a complete timeline of the Application process so that you meet and exceed any deadlines. Look at your timeline daily, sync it with your calendar so that you know when those deadlines are coming up (set reminders).

Be thoroughly familiar with your undergraduate institution’s pre-med protocol process. You don’t want to find out that you need to do something at the last minute. Your pre-med advisor’s office is your best resource for this. Follow the protocol and know everything about it far in advance.

Make a folder for each school that you apply to. In that folder place a copy of every piece of correspondence and every person who helps you in any way (again, letters of thanks are needed here too if someone does something significant for you). Add dates of interviews etc., to your calendar when you receive them.

Keep copies of everything that goes into your application. This includes your personal statement when completed, all of your transcripts (unofficial copies will do). You want to be thoroughly familiar with every word on your application.

In terms of your mental state, force yourself to stop comparing yourself to others or even listening to the woes or brags of others. You are you and the best you can do is be a better version of yourself today than you were yesterday.

If you have never interviewed for anything in your life, get some help from the career center at your institution. Interviewing for any professional school is quite similar to interviewing for your first job. Let them guide you and give you tips, hints and information. Be sure to practice in front of a mirror in the clothing that you anticipate wearing to your interview. Be sure to break in any new shoes or clothes so that you are relaxed and comfortable.

Along the line of clothing and appearance, this is not a time that you want to try a new look or an extreme look that you might not be comfortable with. Comfort and relaxation are the keys to performing well in any new situation. Spend some time now, experimenting with any new looks that you anticipate trying out. Again, the career center at your college/university is a great resource if you need a bit of buffing in this area.

Make a travel budget and stick to it. You don’t want to have to purchase an expensive ticket at the last minute. Plan to arrive the night before and scout out where you need to be, how long it will take for you to get there and be prepared for flight cancellations/delays thus arrive as early as you can.

If you don’t know the cities that your prospective schools are located in, this is a great time to research them. The New York Times “36-Hours In” Series is a great place to start. You can’t do too much research in this area so that you are not stressed needlessly. You can also get an idea of where you might live and what transportation will be like. For example, traffic in some urban area such as LA or San Francisco can be brutal. Are you prepared to deal with that on a daily basis and keep your sanity?

Look at the application process as the next step in your career. You have come this far with excellence, now take this next step with the same excellence. It’s going to be stressful but handle that stress as best you can. As I have written in other posts, being in good physical condition is key to stress management. I am a distance runner which helps my stress level greatly but anything physical such as swimming, basketball, biking or even regular brisk walks can reduce your natural stress level an add to your health.

Finally, speak with folks who have gone through this process the year before. Listen to their experiences and get the best information that you can obtain. Try to speak with people who are first-year medical students at the schools that you anticipate applying to. They are happy to tell their stories so that you can learn from them. Be sure to speak with people who are reapplying too because they can let you know great information. Enjoy this next step as best you can but be as prepared as you can.

At last, I learn patience, calmness and quietness in my practice. I consciously take time on my morning run and meditation to remind myself to listen to those around me before I speak and before I act. For many years, I let my brain move by instinct, honed by training but now, I temper with mindfulness of the moment with more connection and patience. It hasn’t been an easy road but it has been more fulfilling.

As a physician/surgeon/scientist, I have trained to observe with my experience and training guiding those observations. Today, I attempt to slow the process, a tiny bit, to allow myself more connection with my observations. Rather than slow my overall practice down, I have become efficient-another gift from my daily early morning running and meditation sessions.

I recently moved from a house that was too big for the simple life I seek. I had found myself going for weeks and not entering may of the rooms of my former house. With a smaller house, I moved things I didn’t need or use out of my life. With a smaller space, high up in the trees, I live uncluttered and unfettered.

I now enjoy the simple order and beauty of living and using everything in my presence. With my newly found simplification and declutter, I find that I must declutter my brain as well. Thus, I listen, I slow down and I have become sleekly patient in all things.

9 February, 2019

Posted by drnjbmd |
medical school |
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As the semester winds down for those who are in school, the temptation to cheat or cut corners becomes problematic. I understand that you are just busy and want to do anything that will lessen the load but cheating carries risks beyond getting caught. Sure, being questioned is stressful but consider other problems with cheating.

Most people will attempt to justify their cheating by saying that, “Everyone does it”, which is not accurate. Most students diligently attempt to complete their exams, papers, and other scholarly activities as honestly as they can. If you copy another person’s work, you are cheating. If you share answers on an exam, you are cheating. If you stash “crib notes” in the loo for consultation, you are cheating.

The other risk with cheating is that once you cheat, you are never honest again. There is no remediation for dishonest, especially in medicine. When a patient is in distress, as others look to you for solutions to that distress, the cheating won’t help you. You can’t “cheat death” and you can’t have a do-over in these matters.

All of us face subjects that challenge us which is part of being a human. When faced with challenges, I try to solve problems so that I can master what needs to be done. I study regularly and constantly making appointments with myself to keep my work covered. Reading and study are my constant companions as a physician which is why I enjoy my work immensely.

I also know that when I do my work as honestly as possible, I figure out where I fall short and make sure that I put extra time on those things that require more intensive study for me. In short, just as I give my sickest patients more time, I give my worst subjects more time. If my mind doesn’t want to focus on the study tasks in front of me, I take a brisk walk or short run to get my focus back. I hate procrastination in myself and have found that my daily, discipline of running has eliminated procrastination.

As the semester winds down, do the best that you can with honesty and reverence. Resolve to increase your focus on those subjects that require more focus; do them first if you have a choice. Force yourself to do the hard stuff because getting past the hard stuff is most rewarding.